LB 

I. MSl 



TREASURY DEPARTMENT 
UNITED STATES PUBLIC HEALTH SERVICE 

HUGH S. GUMMING, Surgeon General 



NUTRITION AND EDUCATION 



BY 



E. BLANCHE STERLING 

Acting Assistant Surgeon 
United States Public Health Service 



REPRINT No. 798 

FROM THE 

PUBLIC HEALTH REPORTS 

November 10, 1922 
( Pages 2798-2808 ) 



22-'2l'3'3^ 




WASHINGTON 

GOVERNMENT PRINTING OFFICE 

1922 



■^""o^raph • • . 



lIBftAWY OF CONGRESS 

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NUTRITION AND EDUCATION.'^ 

By E. Blanche Sterling, Acting Assistant Surgeon, United States Public Health Service. 

Two insistent questions arise in the minds of thoughtful parents 
everywhere : Shall I send my child to school as soon as the law says 
he is old enough to go, or would it be better for his health if I kept 
him out till he is older ? If he seems brighter than the average child, 
will it be detrimental to his health to permit him to be " accelerated " — 
to make as rapid progress through the school grades as his teachers 
desire ? 

The answers to these questions, from both physicians and educa- 
tors, have been usually merely an expression of opinion colored by 
the viewpoint of the person consulted. In view of the contradictory 
character of the data on which a reply to such questions might be in 
some measure based, and in order to study the subject in what might 
be called a fairly typical American community, the present investi- 
gation was made in the schools of a small city in the Middle West. 
This school system might be called a representative one, comprising; 
three elementary schools, a junior high school, and a senior high 
school. The superintendent was a man of good professional training 
and progressive outlook, and many of his teachers were excellent. 
A very large majority of the pupils were of native American stock or 
of English, Scotch, or Irish ancestry. 

Though it is believed that the relation between height and weight 
according to existing standards is not always a reliable index of the 
child's health, this criterion is used in these studies because no simple 
accurate measure applicable to large numbers is at present available. 
The arbitrary 7 per cent "line" was used to separate the children 
into two classes, those falling 7 per cent or more below tne average 
standard of weight for height and age being considered under 
weight. In these studies the 7 per cent "line" is considered as a 
standard of attainment and possibly as an indication of poor physi- 
cal condition on the part of the child that falls below it. From this 
standpoint it is felt that the comparative studies in this investigation 
will prove sufficiently suggestive to stimulate further research in 
the same subject. 

In this investigation the results of the spring weighing rather than 
the fall weighing are used, because it is believed that the later weight 
serves as a better indication of the relation between health and 
school life. 

a Reprint from the Public Health Reports, Vol. 37, No. 45, Nov. 10, 1922, pp. 2798-2808. 

23336—22 1 



2 



NUTRITION AND EDUCATION. 



A general survey of the school population showed that of 2,068 
children weighed and measured in one of the spring months, 487, or 
23.5 per cent, were under weight. 

This underweight was distributed among the schools as follows: 

Table I. — Correlation oj nutrition and periods of school life. 



School. 



Number 
of chil- 
dren 
weighed. 



Number 
under 
weight. 



Percent- 
age un- 
der 
weight. 



Elementary (3) 

Junior high 

Senior high 



1,126 
520 
422 



2.37 
124 
126 



21.0 
23.8 
29.8 



On the surface, these figures would indicate a moderate increase of 
underweight during school life. But such a conclusion would 
scarcely be justified without a fuller knowledge of growth and 
development during adolescence than can be derived simply from the 
height-weight-age index. Undoubtedly, as shown by the results of 
experienced estimation of nutrition by the Dunfermline scale and 
by critical study of the greater relative variation in weight in children 
with increasing age, other factors must be taken into consideration in 
estimating the physical fitness of all children and particularly of 
adolescents. It is generally believed that there is a greater amount 
of malnutrition among younger children than among older ones. An 
evaluation of nutrition by the Dunfermline scale, the use of which 
presupposes medical training and experience, has given results 
directly opposed to those shown in Table I, where the classification 
is based solely on height, weight, and age. In a study of nearly 
10,000 school children made by the United States Public Health 
Service ^ there is shown a decrease in malnutrition from the younger 
to the older ages. 

A statistical study ^ of anthropometric data collected by officers 
of the Public Health Service brought out the fact that relative 
variation in weight of children of given height increases appreciably 
with age. Since older children vary in weight more than younger, 
a 7 per cent line of demarcation is too restricted for the high-school 
age. With wider normal variations, the margins allowed for under- 
weight and overweight must be greater. 

A similar variation has also been observed by Baldwin.^ 

The data considered in the preceding discussion concern children 
of all ages for grade — the normal age for grade, the overage, and the 

1 Clark, Tahaferro: Nutrition in School Children. Jour. Am. Med. Assoc., vol. 79, No. 7, Aug. 12, 1922, 
pp. 519-524. 

2 Clark, Taliaferro, Sydenstricker, Edgar, and Collins, Selwyn, D.: Heights and Weights of School 
Children— A Study of the Heights and Weights of 14,335 Native White School Children in Maryland, 
Virginia, and North and South CaroUna. PubUc Health Reports, vol. 37, No. 20, May 19, 1922, pp. 1185- 
1207. (Reprint No. 750.) 

^Baldwin, B. T.: The Physical Growth of Children from Birth to Maturity. University of Iowa Studies 
in Child WeKare, First Series, No. 50. Vol. I, No. 1, June 1, 1921. Iowa City, Iowa. 



NUTRITION AND EDUCATION. 3 

underage pupils. To shed some light on the problem of the most 
desirable age for the various periods of school life, it is necessary to 
study these groups separately. This part of the work was limited 
to the elementary and junior high schools. 

Nutrition and Age for Grade. 
ELEMENTARY SCHOOLS. 

Normal-age-for-grade children. — Of 572 normal age for grade children 
in the elementary schools, 118, or 20.6 per cent, were underweight 
at the final weighing in March. Only 12, or 3.4 per cent, of the 346 
children who were above the 7 per cent line at the beginning of school 
in the fall, fell to or below it during the school year. Apparently, 
only 3.4 per cent of these normal- age children were adversely affected 
by conditions during the school term, or by their school work. 

On the other hand, 120, or 53 per cent, of the 226 children who 
were under weight on entering school in the fall went above the 
7 per cent line during the year. 

It might be stated that some nutrition work was carried on in the 
schools during this period, but this work was conducted quite irre- 
spective of the age for grade status of the children. Since the 
effect of these measures will be felt in all groups, they may be largely 
disregarded in a comparative study of the groups. 
. Overage-for-grade children. — There were 465 overage for grade 
children in the elementary schools. Of this number 105, or 22.6 per 
cent, were under weight at the spring weighing. Of the 282 overage 
children who began the school year with less than 7 per cent under- 
weight, 8, or 2.8 per cent, fell to or below that line during the year in 
school. 

On the other hand, of 183 children underweight in the fall, 86, or 
46.9 per cent, came up to the standard by the spring. As in the case 
of the normal-age children, the number gaining was vastly superior 
to the number losing during the school year. It is interesting to 
note that the ratio of loss to gain is so nearly the same in these two 
groups. 

Underage-for-grade children. — The number of children under age 
for grade in any school will naturally be less than the number of 
either normal-age or overage pupils. The majority of children are 
sent to school -at the normal age and advance at the normal rate, 
though large numbers, for one reason or another, are found among 
the overage-for-grade pupils. In the elementary schools studied there 
were 92 underage-for-grade pupils. Of this number 20, or 21.7 per 
cent, were underweight at the spring weighing. Fifty of these under- 
age children were up to the standard of weight when they be^an 
school in the fall, and only 1 of them (2 per cent) fell below it during 
the period of observation. Of 42 underage children who were under- 
23336—22 2 



4 NUTRITION AND EDUCATION. 

weight in the fall, 23, or 54.7 per cent, could not be so classified in 
the spring, because they had come up to the standard. 

In Table II the data relating to the elementary schools have been 
arranged for the purpose of easy comparison. 

Table U.— Correlation of nutrition and age for grade in elementary schools. 









Per cent 


Per cent 










of under- 


of normal 










weight 
children 
attaining 


weight 






Number 


Per cent 


children 
faUing 


Per cent 
taking 


Age for grade. 


of chil- 


under- 


standard 


below 




dren. 


weight. 


of weight 


standard 


lunch. 








during 


during 








period of 


period of 










observa- 


observa- 










tion. 


tion. 




Normal age 


572 
465 
92 


20.6 
22.5 
21.7 


53.0 
46.9 
54.7 


3.4 
2.8 
2.0 


70 




52 




69 







It will be seen at a glance that the amount of underweight among 
the normal-age, overage, and underage pupils in the early spring is 
practically the same. From the standpoint of weight it seems evi- 
dent that the year in the schools investigated was not detrimental 
to the health of the pupils; the descent into the underweight class 
among those who were not there in the beginning has been remark- 
ably limited in extent. 

The marked increase in weight in each group is probably due 
partly to the fact that the maximum increment takes place normally 
between October and February "* and to the milk lunch furnished at 
the morning and afternoon recesses, in addition to some instruction 
in nutrition. Since school feeding is a recognized part of school 
hygiene and has been incorporated in the school system studied, this 
feature of the school life of this community should have equal con- 
sideration in relation both to the health of the pupils and to the 
school work. It is interesting, therefore, to note the close correla- 
tion between the percentage taking the milk lunch and the percentage 
showing weight increase during the year. Practically the same per- 
centage of normal-age and underage children had the milk lunch at 
some time during the year, and the percentages of these two groups 
attaining the weight standard are almost the same. A considerably 
smaller percentage of overage children took the milk and a corre- 
spondingly smaller percentage of these children came up to weight 
during the year. It would be unfair to any school system to consider 
only the school side of the work and ignore all specific measures 
undertaken to safeguard the health of the pupils. 

In order to gain some idea as to how far physical defects may 
have influenced the weight status of the pupils, a study was made 

* Porter, W. T.: Seasonal Variation in the Growth of Boston School Children. Am. Jour, of Phys., 
May, 1920, vol. 52, pp. 121-131. 



NUTRITION AND EDUCATION. 



of physical defects in relation to age for grade. The results are 
summarized in Table III. 

Table III. — Physical defects and age for grade. 



Age for grade. 



Average 
number 

of 

physical 

defects 

per pupil. 



Overage 

Normal age. 
Underage. . . 



1.57 
1.44 
1.41 



A comparison of Tables II and III shows that among the overage- 
for-grade pupils there was slightly more underweight and a slightly 
higher average of physical defects per pupil. In other words, the 
overage pupils in the elementary schools were a little lighter' in weight 
and had a slightly higher average number of physical defects per 
pupil than feither the normal-age or underage pupils. These differ- 
ences, however, are slight. 

JUNIOR HIGH SCHOOL. 

All of the seventh and eighth grade pupils, most of the sixth-grade, 
and a few fifth-grade children were taught at the junior high school 
by the usual methods in vogue at institutions of the same character. 
Most of the year there was considerable overcrowding at this school. 

Overage-for-grade pupils. — There were 268 overage children in the 
junior high school, and 68, or 25.4 per cent, of this number were 
found to be underweight in the spring. One hundred and sixty of 
these children entered school in the fall in a well-nourished condition, 
and all but 5, or 3.1 per cent, maintained this position in the spring. 
Of the 108 children who were underweight at entrance, 45, or 41.6 
per cent, came up to the required standard by the time of the spring 
weighing. 

Underage for grade. — The number of underage children in the junior 
high school was small, only 56 pupils coming under this classification. 
Of these, 20, or 35.7 per cent, were underweight in the spring. One- 
half (28) of these underage children were up to the weight standard 
on beginning the school year, and all but one (3.5 per cent) held this 
position at the end of the year. 

Of the other half of this group — those children who were under- 
weight in the fall — 9, or 32.1 per cent, came up to standard by the 
time of the spring weighing. 

The data for supplying exact figures relating to normal-age chil- 
dren in the junior high school are lacking, but it is easy to see from 
the percentage of underweight of all the children in the school and 
from the figures for the overage and underage pupils that the per- 



-6 



NUTKITION AND EDUCATION. 



centage of underweight children among the normal-age children 
would be about 20. 

Table IY .—Correlation of nutrition and age for grade in junior high schools. 



Age for grade. 



Overage... 
Underage. 



Number 

of 
children. 



268 
56 



Per cent 
under- 
weight. 



25.3 
35.7 



Per cent 
of under- 
weight 
children 
attaining 
standard 
weight 
during 
period of 
observa- 
tion. 



41.6 
32.1 



Per cent 

of 
normal 
weight 

children 
falling 
below 

standard 
during 

period of 

observa- 
tion. 



3.1 
3.5 



There were 90 pupils in the junior high school who had the milk 
limch for varying periods dm-ing the school year, but their distri- 
bution as to age for grade is not sufficiently well known to be of use 
as a comparative factor. It may be said, however, that the correla- 
tion noted in the case of the elementary schools points to the influence 
of this feature in the weight increases. 

The point of most interest in Table IV is the large percentage of 
underweight among the underage-for-grade children in the junior 
high school. Does this mean that the work of the junior high school 
is detrimental to the health of the young pupil, and that a child 
should not be allowed to enter that school unless he has reached at 
least the normal age for his grade ? But reweighing in March showed 
that almost exactly the same percentage of overage pupils had 
fallen below the standard as underage pupils. In other words, the 
older children lost in exactly the same proportion as the younger 
ones. 

A comparison of the gains in these two groups shows a larger per- 
centage in the overage group; but since this is complicated by the 
question of extra nutrition, and since data regarding age-for-grade 
and milk lunches are incomplete, the comparison may not be a safe 
one. A reweighing in June would have been desirable, particularly 
in the junior high school. 

Since to say that a child is underage for grade means that he has 
reached a certain school grade at an age younger than the normal, 
it usually means also that he is brighter mentally than the average 
child. May it be possible that these lighter-weight children at this 
particular age period are brighter than the heavier children? This 
is in contrast to the findings in Detroit ^ but agrees with those 
reported by the Bureau of Educational Experiments ® with reference 

s Packer, Paul C, and Moehlman, Arthur B.: A Preliminary Study of Standards of Growth in the 
Detroit Public Schools. The Detroit Educational Bulletin, No. 5, June, 1921. 

6 Hunt, J. L., Johnson, B. J., and Lincoln, E. M.: Health Education and the Nutrition Class. E. P. 
:Dutton & Co., New York, 1021. 



NUTKITION AND EDUCATION. 



to the Terman classes. These classes were made up of exceptionally 
"bright pupils from the sixth, seventh, and eighth grades (junior 
iiigh-school grades) and contained a much larger percentage of 
underweight children than the regular sixth and seventh grades. 

Nutrition and Acceleration. 

The underage child is not necessarily the accelerated child. If a 
child begins earlier, he will reach a class before the normal-age child, 
though both travel at the same rate. The really accelerated child is 
lihe one who covers more ground in the same time. In this sense 
there were a number of accelerated pupils in both the elementary 
.schools and the junior high school. 

In the elementary schools there were 63 accelerated pupils,^ 27 per 
•cent of whom at the last weighing were underweight. It will be re- 
•called that the percentage of underweight among all the children in 
the elementary schools was 21. These exceptional children, with a 
percentage of 27, are lighter than the general run of children in the 
■elementary schools. The age-for-grade and nutritional status of the 
group are shown in Table V. 

Table \ .^Correlation of nutrition and acceleration in elementary schools. 



Age for grade. 



Number 
of pupils. 



Number 
under- 
weight. 



Per cent 
under- 
weight. 



All ages. . . 

Overage 

Normal age 
Underage. . . 



27.0 
20.0 
30.7 
22.2 



It will be seen from this table that the largest percentage of under- 
weight is among the normal-age children and the least among the over- 
age. The overage children are slightly heavier than the underage 
children m this exceptional group. 

It was especially desired to ascertain whether the March weighing 
would show any unfavorable results as regards weight from the extra 
school work which these children had undertaken. The data on this 
<][uestion are presented in Table VI. 

Table VI. — Nutritional changes from October to March among accelerated children in the 

elementary schools. 



Age for grade. 


Children gaining 
good nutritional 
status. 


Children losing 
good nutritional 
status. 




Number. 


Percent. 


Number. 


Per cent. 




11 
3 
6 
2 


44.0 
60.0 
37.5 
50.0 


3 
1 
2 



7.9 




10.0 




8.7 




0.0 







' Accelerated pupils are permitted to take additional studies, making it possible to advance more than one 
grade a year. 



8 



NUTEITION AND EDUCATION. 



As in other classes in the schools, the percentage of gains i& 
much greater than the percentage of losses. While the average 
percentage of gains is very much the same in the accelerated group 
and the elementary schools as a whole, it must be acknowledged 
that the percentage of losses is greater among the accelerated pupils. 
However, the numbers in the various age-for-grade groups — overage, 
normal age, and underage — -are too small to give their statistics 
much value, and it is only in the group as a whole that the percentage 
of loss can be given much consideration. This percentage, 7.9, is 
twice as great as that for any age group in the elementary schools 
as a whole. To recapitulate, among a group of 63 accelerated chil- 
dren of various ages, distributed through the elementary grades, 38 
were in good nutritional status in the fall, and 25 were underweight. 
Of the 38 up to the standard of weight, 3, or 7.9 per cent, fell to or 
below it during the year. Of the 25 underweight pupils, 11, or 44 
per cent, came up to the standard. 

Acceleration in the Junior High School. 

In the junior high school there were two accelerated classes in 
the seventh and eighth grades, a total of 67 pupils. 

Table VII. — Correlation of nutrition and acceleration in junior high school. 



Age for grade. 



Number 
of pupils. 



Number 
under- 
weight. 



Per cent. 



All ages . . . 
Overage... 
Normal age 
Underage.. 



32.8 
0.0 
30.0 
43.4 



Table VII shows that the percentage of underweight in these 
accelerated classes, 32.8, is greater than that in the junior high 
school as a whole, which is 23.8 per cent. The percentage of under- 
weight among the underage pupils is considerably greater than 
among the normal age. The few overage children in the group 
are all up to the standard of weight. 

As in the case of the elementary schools, the last weighing in the 
spring was compared with the first weighing in the fall. The result 
is given in Table VIII. 

Table VIII. — Nutritional changes from October to March among accelerated pupils in 

the junior high school. 



Age for grade. 



All ages 

Overage 

Normal age 
Underage. . 



Children gaining 
good nutritional 
status. 



Number. Per cent, 



33.3 
100.0 
33.3 
28.5 



Children losing 
good nutritional 

status. 



Number. Per cent. 



5.4 
0.0 
8.0 
0.0 



NUTRITION AND EDUCATION. 9 

In the various age groups the numbers are too small to be sig- 
nificant. The number of overage pupils is too few to be considered. 
Of the four overage pupils, only one was underweight in the fall, and 
that one came up to the standard. 

Taken as a whole, however, the findings in this group are suggestive. 
Of these 67 pupils, 37 were in good nutritional status in the fall and 
30 were underweight. Two of the 37, or 5.4 per cent, fell to or below 
the line between October and March; while of the 30 underweight 
in the fall, 10, or 33.3 per cent, came up to the standard. It may be 
noted that the percentage of those changing from a poor to a good 
nutritional status is less in the junior high school than in the ele- 
mentary schools. 

Table IX. — Nutrition, age for grade, and acceleration in elementary and junior high 

schools. 



Classification. 



Per cent 
under- 
weight. 



All pupils 

Over-age-for-grade pupils. . . 
Under-age-for-grade pupils. 
Accelerated pupils 



Summary. 

The work of the elementary grades apparently had little, if any, 
adverse effect on the pupils' weight. Of the children who entered the 
schools up to the standard of weight in the fall, remarkably few were 
under weight in March. This was entirely irrespective of the age of 
the pupil, the underage child making quite as good showing as the 
normal age or overage child. 

There was a slightly larger amount of underweight among the 
overage children in the elementary schools, as well as a slightly 
larger average number of physical defects per child. 

There was a large percentage of underweight among the underage 
■children in the junior high school. Also there was a larger percentage 
of underweight among the bright children in the accelerated groups, 
both in the elementary and junior high schools, than among the 
other children. 

As in the elementary schools, there was shown to be only a small 
percentage of change from a good to a poor nutritional status in the 
junior high school, from October to March, among the children 
doing regular grade work. 

Acceleration in the elementary schools shows a larger percentage of 
change from good to poor nutritional status than does acceleration in 
the junior high school, or the regular grade work of either school. 
In the accelerated classes of the junior high school similar changes 



10 NUTEITION AND EDUCATION. 

are less than among the accelerated pupils in the elementary schools, 
but greater than among the children doing regular grade work. It 
must be remembered, however, that a much larger number of accel- 
erated children should be studied in order to arrive at results which 
might be considered as in any way definitely conclusive. 

Conclusions. 

In view of the data summarized above, it is evident that at least 
tentative answers may be given to the questions which furnished the 
motive for this investigation and which have been stated in the 
beginning of the report. It must be remembered, however, that the 
number of pupils studied is somewhat limited, and that the findings 
apply to the particular school system studied. It is to be hoped 
that other investigators will pursue studies similar to this one in order 
that additional evidence on these important subjects may be forth- 
coming. 

1. Since it was shown quite definitely that few of the children who 
were up to the standard of weight on entering the elementary schools 
in the fall were below that standard six months later, and that this 
was true irrespective of the age of the pupil, it follows that parents 
need not hesitate to send a healthy child to school at the age of 6, 
which was the entrance age of the schools studied. It seems plain 
that school life, apart from detrimental influences which may exist 
in the home environment, is not ordinarily a menace to the child's 
state of nutrition. 

2. As acceleration in the elementary schools shows a larger per- 
centage of change from a good to a poor nutritional status than does 
acceleration in the junior high school, or the regular grade work of 
either school, it would seem that cai^tion should be observed in 
accelerating young children — those of the elementary school age. 
At the junior high school age this need is not so evident, although it 
apparently exists to some extent. 



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